Somatisation Flashcards
Define
The main features are multiple, recurrent and frequently changing physical symptoms of at least 2 years duration
- Many have a complicated history of contact with medical care -> many negative investigations carried out
- Symptoms may be referred to any part or system of the body
- The disorder is chronic and fluctuating à disruption of social, interpersonal and family behaviour
Epidemiology/ Aetiology
Epidemiology
- Most commonly affect women
- Onset is often in early adult life
Aetiology
- The unconscious expression of psychological distress may manifest through these physical symptoms
- Psychiatric illness- depression and anxiety symptoms can be psychological and physical
- Cognitive models- an individual’s interpretation of normal physiology can create anxiety and perpetuate this
The following factors are important in the aetiology:
- Chronic and/or acute intrapsychic (emotional/ psychological) stress or conflict
- Emotional processing deficits
- Social, cultural or family taboos against emotional expression
- The course of the disorder is chronic and fluctuating
- It is often associated with disruption of social, interpersonal and family behaviour
Co-morbid background:
- Anxiety
- Depression
- Alcohol abuse
- Substance abuse
- Histrionic PD
- Dissocial PD
Types
Undifferentiated Somatoform Disorder
- Multiple, varying & persistent complaints of <2 years duration (i.e. not full definition)
Hypochondrial Disorder
- Often CANCER
- Pre-occupation with a SINGLE problem
- Persistent preoccupation with idea of having serious/progressive physical disorders Normal sensations interpreted as abnormal or distressing
- Co-morbid anxiety and/or depression common Patient maintains their belief despite being told otherwise (overvalued idea)
Somatoform Autonomic Dysfunction Symptoms presented as if due to physical disorder of system/organ largely or completely under control of the ANS (i.e. cardiovascular, GI, respiratory):
- Objective autonomic arousal (palpitations, sweating, flushing, tremor)
- Subjective non-specific (fleeting aches/pains, burning sensation, bloating)
Persistent Somatoform Pain Disorder
- Persistent, severe and distressing pain (not otherwise explained)
- Evidence of emotional conflict or psychosocial problems
Signs/ symptoms
Long and complicated history of contact with both primary and specialist medical care services- many negative investigations or exploratory operations
Symptoms can include different systems:
Gastrointestinal: nausea, vomiting, diarrhoea, constipation, food intolerance, abdominal pain
Sexual or reproductive: loss of libido, ejaculatory or erectile dysfunction, irregular menses, menorrhagia, dysmenorrhoea
Urinary: dysuria, frequency, urinary retention, incontinence
Neurological paralysis, paraesthesia, sensory loss, seizures, difficulty swallowing, impaired coordination or balance
Cardiology: non-cardiac chest pain, palpitations
Rheumatology fibromyalgia
Persistent pain- often rheumatological
Patients often dependent on analgesics and sedatives due to frequent courses of medication
Diagnosis
Diagnosis:
- At least 2 years of symptoms with no physical explanation found
- Persistent refusal by the patient to accept reassurance from several doctors that there is no physical cause for the symptoms
- Some degree of functional impairment due to the symptoms and resulting behaviour
Full history and MSE (with physical examination)
Exclude organic cause (i.e. stroke)
Exclude co-morbid conditions (i.e. with HADS for potential depression and anxiety)
DDx
Organic - rule out any possible physical cause. Even if symptoms are multiple and changing, a multisystem physical illness may be responsible, e.g. sarcoidosis, occult malignancy, chronic infections (e.g. tuberculosis, HIV).
Psych illness
* Anxiety and depression can cause exacerbation of symptoms
* Hypochondriasis
* Schizophrenia/ persistent delusional disorder
Deliberate production of symp (rare)
- Factitious disorder: the deliberate production of symptoms to receive medical treatment. Presentations include pyrexia of unknown origin, haematuria, and skin lesions. Extreme cases are termed Munchausen’s syndrome.
Malingering: feigning symptoms to obtain external reward, e.g. escape military service, gain money or drugs.
Management
mostly based as counselling in the interview:
Continuity of care (seen by the same doctor each time)
- 1st line: explain and reassure:
- 1st: Broaden clinical agenda from physical cause to a physical and psychological cause
- 2nd: Be clear about negative clinical findings and link the symptoms to psychological causes:
- Acknowledge psychosocial distress
- Elicit childhood experience of illness
3rd: Explain you’ll not conduct further investigations (and state why you are stopping)
4th: Emotional support:
· Encourage coping strategies and letting go of an inappropriate sick role
· Involve family who may be reinforcing behaviour
· Encourage normal function (i.e. activities)
- 2nd line: CBT
- Treat co-morbid conditions (i.e. depression)
Complications / Prognosis
Complications
- Depression
- Anxiety
- Suicidal ideation
- Substance use/ abuse
Prognosis
- Remission rate is very low
- Patients with many somatic symptoms, anxiety or depression and old age or impairment are more likely to have persistent symptoms
PACES
PACES
Acknowledge how the symptoms are real - but there may be a link between how you are feeling in your mind and what is going on in your life
Not saying pain is in your mind, but sometimes the way things are going/ our feelings can manifest as very real physical symptoms
Explain how it is v normal, i.e., when you are embarrassed you blush or feel nervous you may feel a pit in your stomach
If are still worried something is being missed then reassure how you want to see them again over the next few months, to see if there are any changes, and if app we can arrange investigations then to make sure we aren’t missing anything .
